<?php defined('BASEPATH') or exit('No direct script access allowed'); ?>
<?php echo form_open(uri_string(), 'id="withdrawal-request-form"')?>
<div id="uploking_box">
	<div id="uploking_box_header">
		<h2><?php echo lang('uploking_withdrawal_request_withdrawal_label')?></h2>
	</div>
	<div id="uploking_box_error"></div>
	<div id="uploking_box_content">
		<div class="uploking-box_input_item">
			<div class="uploking_box_label"><?php echo lang('uploking_withdrawal_money_amount_label')?></div>
			<div class="uploking_box_input"><input type="text" id="money" name="money" value="" class="uploking_input_text"></div>
			<div class="clear"></div>
		</div>
		<div class="uploking-box_input_item">
			<div class="uploking_box_label"><?php echo lang('uploking_withdrawal_paypal_email_label')?></div>
			<div class="uploking_box_input"><input type="text" id="paypal_email" name="paypal_email" value="" class="uploking_input_text"></div>
			<div class="clear"></div>
		</div>
		<div class="uploking-box_input_item">
			<div class="uploking_box_label"><?php echo lang('uploking_withdrawal_pin_number_label')?></div>
			<div class="uploking_box_input"><input type="text" id="pin_number" name="pin_number" value="" class="uploking_input_text"></div>
			<div class="clear"></div>
		</div>
		<div class="uploking-box_input_item">
			<div class="uploking_box_label">
				&nbsp;
			</div>
			<div class="uploking_box_input">
				<input type="button" value="<?php echo lang('uploking_new_folder_cancel_label')?>" id="withdrawal_request_cancel" class="uploking_button">
				<input type="submit" name="request" value="<?php echo lang('uploking_withdrawal_request_label')?>" id="withdrawal_request_submit" class="uploking_button">
			</div>
			<div class="clear"></div>
		</div>
	</div>
</div>
<?php echo form_close()?>
